Rib Graft Rhinoplasty

Q: Dr. Eppley, As you know, there area number of procedures I am looking to get done, and I wanted to get your opinion on one of them as I read some excellent articles you wrote on the use of rib cartilage as grafting material for Asian rhinoplasty.

One of the procedures I would like to have performed is revision rhinoplasty as my implant is not completely straight, and I do not think the shape is successful. I believe it’s difficult for surgeons to really shape rib cartilage, and wanted your thoughts / opinion on shaping it for a very feminine look: a good height, generally slim bridge and width, with a curved line all the way to the tip. How can this best be done and what is your experience?

A: You are correct in rib graft rhinoplasty that shaping rib cartilage can be difficult and there is always the risk of it warping after surgery. If the rib graft can be ideally shaped as a solid piece to achieve your goals then that would be a good method to do it. But between the shape of the harvested rib and the unpredictability of whether it will warp its fashioned shape, this has led to the use of a diced cartilage graft approach. This allows it to be molded into its desired shape. This is the preferred approach in many cases of rib graft rhinoplasty today.

Dr. Barry Eppley

Indianapolis, Indiana

Revision Rhinoplasty

Q: Dr. Eppley, I have spoken with you a few times about a getting a revision rhinoplasty procedure. I’m getting very close to scheduling my consultation and procedure with you. I have a question in the event I want any corrections after my procedure how long will I have to wait for a revision? I don’t want any additional surgeries after this one, but I wonder will a quick follow up procedure cause damage to my previous cartilage graft?

A: Like all rhinoplasties, whether they are primary or secondary, any efforts at revision rhinoplasty should wait a minimum of six months so the tissues have time to return to a more normal state so they can tolerate surgical manipulation. This is also an adequate amount of time for all nasal swelling to subside and one can appreciate that their concerns are stable and no new shape concerns have arisen.

Secondary revision rhinoplasty surgeries will not damage previously placed cartilage grafts. Cartilage grafts in the nose are quite hardy and are only damaged (undergo resorption) in the presence of infection. Otherwise they can be worked around, over and even removed and replaced without affect their survival and structural support.

Dr. Barry Eppley
Indianapolis, Indiana

Tummy Tuck

Q: Dr. Eppley, Does tummy tuck surgery include work on the abdominal wall? I am hoping to get some relief from back pain and my chiropractor suggested I get my abs strengthened.

A: Tummy tuck surgery does tighten the abdominal muscles (vertical rectus muscles) as part of the procedure. That does not necessarily mean it makes them stronger however. It just makes them pouch out less. Whether this would improve your back pain can not be predicted with any certainty.

I think what your chiropractor was suggesting is that you work on making your abdominal muscles stronger by exercise…not necessarily by surgery. (although I was not part of that conversation so I can not say for sure) Abdominal wall muscle plication is done to provide greater structural rigidity particularly when there are defects in the abdominal wall. While a rectus diastasis is not the same as a hernia (it is a weakening of the abdominal wall not an actual defect through it), bring the muscles back together in the midline helps provide better abdominal wall support. This theoretically should help someone with chronic back pain although it is not because the abdominal muscles are stronger per se. They are simply more rigid or tighter in a vertical direction.

Dr. Barry Eppley
Indianapolis, Indiana

Rib Removal

Q: Dr. Eppley, I would like to ask about rib removal surgery. How many ribs will be extracted if I want a thinner waist as well as a longer torso. Also, I’d like to know about post surgical pain and recovery period. Thanks.

A: Thank you for your inquiry. Rib removal surgery is a collection of procedures designed to treat various torso issues. There are ribs removed to narrow the waistline (ribs 10,11,12) or to vertically lengthen the waistline. (rib #s 7,8,9) The lower ribs are removed through incisions on the back while the upper ribs are removed through incisions on the front. If both are done at once as many as portions 12 ribs can be removed.  (ribs are not totally removed only portions of them are) I would need to see pictures of your waistline/torso to determine if either of these ribcage modification procedures are appropriate for you.

Postoperative discomfort is managed by the use of intraoperatively placed Exparel injections as nerve and muscle blocks that last as long as three days after surgery. This goes a long way in helping control what would otherwise be an uncomfortable experience.Recovery depends on what type of physical activity one is trying to recover for.

Dr. Barry Eppley

Indianapolis, Indiana

Sliding Genioplasty

Q: Dr. Eppley, I had a sliding genioplasty two years ago and I’m not fully satisfied because I would like more projection. The surgeon is brilliant and he did everything very well but I just want a little more. Is it possible to repeat a sliding genioplasty and will the bone heal the same? 

Also 10 months after the operation when I visited the surgeon who performed the genioplasty he pressed quite hard on my chin with his thumbs to feel the bone. Could that have pushed it back or am I just paranoid? Is the bone, plate and screws strong enough for that kind of treatment after ten months? 

I visited him again 16 months after the operation and he did the same thing again. 

I also hit my chin a little when I pulled my cover up while sleeping yesterday. I’m constantly worried that it’s shifting or lose. Do I need to be? 🙁 

Sorry for such a long message. Thank you!

A: There is no reason that you can not have a secondary bony sliding genioplasty years later that would heal just as well as the first one. While there is no good reason to be pushing on the bone, there is no risk of causing it to move backward. The plate and screw fixation is more than adequate to resist any displacing forces early after surgery and the healing of bone s more than adequate to do so months to years later.

Dr. Barry Eppley

Indianapolis, Indiana


Q: Dr. Eppley, I have a small lipoma on my stomach that I’m interested in having removed without a scar. I found some of your posts relating to this issue and LipoDissolve (Kybella) seems like a viable alternative. Your post mentioned that it might take multiple injections, do these injections have to be within a certain amount of time? I work outside the US most of the year and only travel home to Indy a few times per year so I might have to spread the injections over a long period of time. 

A: The only non-surgical alternative to surgical excision of a lipoma is injection therapy. While one known as Lipodissolve, it is now known as Kybella injections. These are pure deocycholic acid injections which help break down the lipoma by disrupting the cell walls of the adipocyutes within the lipoma capsule. Over the years I have treated a fair number of lipomas with injections and it almost always takes ore than one injection treatment to get the maximal reduction. While I usually space these as close as 6 weeks apart, there is no harm in having much longer periods between the injection sessions. It does not adversely affect the injection’s effectiveness.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Jawline Implant

Q: Dr. Eppley, The side profile shot is taken of what I consider my weaker side, though the left side has only slightly better bone and muscle definition, it is a noticeable difference. Its something I have been conscious of all my life – lowering and pushing my jaw forwards in photos etc and now as I get older, it appears to be more noticeable. 

I’m not looking for a wide angular jaw bone as I have an oval face and a fairly small head size so that would look weird. I’m relying on your aesthetic appreciation of my request based on the following considerations to hopefully provide a stronger, but normal looking, less saggy and symmetrical jaw line.

1. To gain a slight vertical lengthening of my jaw line
2. Consider the amount/effect (if any) of slight vertical lengthening of my chin with this procedure. Or will this make my face unbalanced?
3. To further enhance the weaker right hand side to correct the slight bone and muscle asymmetry to match the left side. 
4. Determine if I would benefit aesthetically by a slight chin projection to help the overall balance and proportion of my face?

Hopefully, if this can be met it will take up some of the slacker soft tissue and negate any surgical lifting and provide balance and proportion? That’s my aim anyway.

I look forward to hearing from you soon.

A: Given your multiple aesthetic needs of your lower jawline, only a custom jawline implant can come close to achieving all of your goals. The addition of vertical lengthening of the jawline as well as some horizontal chin increase can only be done by such an implant. Because the custom jawline implant adds overall bony volume it will by definition pick up some loose tissue along the jawline.

Dr. Barry Eppley
Indianapolis, Indiana

Facial Reshaping

Q: Dr. Eppley, I have some questions having to do with facial reshaping.

1. Is there a limitation in how many millimeters can one widen the cheekbones with a zygomatic osteotomy?

2. Since custom made cheek implants can be created as large as a patient desires, will the dimensions of the implants follow the dimensions of the widening result of the face or more specifically the soft tissue of it? For example, if a patient was to have inserted cheek implants that were about 5 mm wide each, would that lead to a total centimeter increase in bizygomatic width, or more and even less than that?

3. Aside from lip lifts, rhinoplasty and cheek implants are there any other effective ways to give an illusion of a shorter pupil to lips distance that appears long on a face? I was thinking that some work around the eyebrows could be a potentially good idea but I’m not sure how this could be done.

Thank you in advance.
A: Thank you for your inquiry. In answer to your facial reshaping questions:

1) Generally 5 to 7mms of out fracture of the anterior arch can be done before there becomes an obvious step-off externally.

2) In onlay custom cheek implants the overlying soft tissues generally follow on a near 1:1 basis.

3) Without seeing pictures of your face I can say what may or may not be effective in decreasing the pupil to lip distance.

Dr. Barry Eppley
Indianapolis, Indiana

Lower Buttock Lifts

Q: Dr. Eppley, I am interested in lower buttock lifts. mI have been trying to correct my saggy buttocks for over a year now. I have been very athleltic all my life and no matter how toned the rest of my body is there is always a saggy pouch below my buttocks. I had fat injections which didn’t take then I asked my surgeon to excise the sagging skin and fat. But he didn’t emove much at all and it’s basically still the same. I have found your website and it appears you know what you are doing with this. So I am wondering if you can correct this (no implants or anything required, simply removal of that pouch) and what sort of recovery I will be facing?

A: Lower buttock lifts are really the only technique that can improve redundant tissue that hangs over the infragluteal fold or loose tissue just under the fold. Please send me some pictures of the your lower buttocks so I appreciate the issue that you have and where your current lower buttock scar is. Most likely your last surgery simply did not remove enough tissue to see much change. The recovery from lower buttock lifts is really only limited by how much you can bend over after the surgery to avoid excessive pulling on the suture line. One should avoid returning to most forms of strenuous exercise for four to six weeks after surgery.

Dr. Barry Eppley
Indianapolis, Indiana

Custom Cheek Implants

Q: Dr. Eppley, Can you please tell me whether a custom high cheek implants for males can also be adapted to provide augmentation to the under eye area? And also can custom cheek implants be designed to give more volume than other implants as I desire noticeably higher cheekbones whilst still looking natural.

cheek-infraorbital-impalnt-vs-standard-cheek-implant-dr-barry-eppley-indianapolisA: It is actually very common to have an infraorbital extension under the eye as part of many custom cheek implants as part of their design. (compared to a standard cheek implant which is the darker blue one) This can be seen in the attached custom cheek implant image example. Not only can there be an anterior infraorbital extension but often there is a posterior infraorbital extension back along the zygomatic arch as well. By definition custom cheek implants are usually bigger and thus have greater volumes than standard sized cheek implants. It is important to know that the design of the implant and the bone that to covers is more important than thickness or size. It doesn’t matter how big the cheek implant is of it is not the right implant style and design. This is why i do so much custom cheek implants as many patients don’t get the right design of the implant for the look they are trying to achieve.

Dr. Barry Eppley
Indianapolis, Indiana